Person-Centered & Experiential Psychotherapies
ISSN: 1477-9757 (Print) 1752-9182 (Online) Journal homepage: http://www.tandfonline.com/loi/rpcp20
Increasing parental self-efficacy with emotionfocused family therapy for eating disorders: a process model Erin J. Strahan, Amanda Stillar, Natasha Files, Patricia Nash, Jennifer Scarborough, Laura Connors, Joanne Gusella, Katherine Henderson, Shari Mayman, Patricia Marchand, Emily S. Orr, Joanne Dolhanty & Adèle Lafrance To cite this article: Erin J. Strahan, Amanda Stillar, Natasha Files, Patricia Nash, Jennifer Scarborough, Laura Connors, Joanne Gusella, Katherine Henderson, Shari Mayman, Patricia Marchand, Emily S. Orr, Joanne Dolhanty & Adèle Lafrance (2017): Increasing parental selfefficacy with emotion-focused family therapy for eating disorders: a process model, PersonCentered & Experiential Psychotherapies, DOI: 10.1080/14779757.2017.1330703 To link to this article: http://dx.doi.org/10.1080/14779757.2017.1330703
Published online: 30 May 2017.
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Date: 31 May 2017, At: 06:09
PERSON-CENTERED & EXPERIENTIAL PSYCHOTHERAPIES, 2017 https://doi.org/10.1080/14779757.2017.1330703
INVITED ARTICLE
Increasing parental self-efficacy with emotion-focused family therapy for eating disorders: a process model Erin J. Strahana, Amanda Stillarb, Natasha Filesc, Patricia Nashd, Jennifer Scarboroughe, Laura Connorsf, Joanne Gusellaf, Katherine Hendersong, Shari Maymang, Patricia Marchandh, Emily S. Orri, Joanne Dolhantyj and Adèle Lafrancek,l a Department of Psychology, Wilfrid Laurier University, Brantford, ON, Canada; bDepartment of Education, University of Alberta, Edmonton, AB, Canada; cThree Story Clinic, Vancouver, BC, Canada; dEating Disorder Foundation of NL, St. John’s, NL, Canada; eCanadian Mental Health Association, Kitchener, ON, Canada; f IWK Health Centre, Halifax, NS, Canada; gAnchor Psychological Services, Ottawa, ON, Canada; hHotel Dieu Hospital, Kingston, ON, Canada; iCape Breton Regional Hospital, Sydney, NS, Canada; jMount Pleasant Therapy Center, Toronto, ON, Canada; kDepartment of Psychology, Laurentian University, Sudbury, ON, Canada; lHealth Sciences North, Sudbury, ON, Canada
ARTICLE HISTORY
ABSTRACT
A process model was tested whereby parental fear and self-blame were targeted in order to enhance parental self-efficacy and supportive efforts in the context of emotion-focused family therapy (EFFT) for eating disorders (ED). A 2-day EFFT group intervention was delivered to parents of adolescent and adult children with ED. Data were collected from eight treatment sites (N = 124). Data were analyzed using t-tests, regression analyses and structural equation modeling. The findings supported the proposed process model. Through the processing of parents’ maladaptive fear and self-blame, parents felt more empowered to support their child’s recovery. This increase in self-efficacy led to an increase in parents’ intentions to engage in recovery-focused behaviors. This study is the first to test a method for clinicians to increase supportive efforts by targeting and enhancing caregiver self-efficacy via the processing of emotion.
Received 30 December 2016 Accepted 20 January 2017 KEYWORDS
Eating disorders; self-efficacy; emotion-focused family therapy; process model
Elterliche Selbstwirksamkeit mit Emotionsfokussierter Familien-Therapie bei Essstörungen. Ein Prozessmodell Ein Prozessmodell im Rahmen von Emotionsfokussierter FamilienTherapie (EFFT) wurde getestet: Elterliche Angst und Selbstvorwürfe wurden bearbeitet, um elterliche Selbstwirksamkeit und unterstützende Bemühungen bei Essstörungen (ES) zu erhöhen. Eltern von adoleszenten und erwachsenen Kindern mit ES bekamen eine zweitägige EFFT Gruppenintervention. Von acht Behandlungsorten wurden Daten erhoben (N=124). Die Daten wurden mit T-Tests, Regressionsanalysen und strukturellen Gleichungsmodellen analysiert. Die Befunde unterstützten das hier skizzierte Prozess-Modell. Durch das Prozessieren ihrer elterlichen maladaptive Angst und ihrer Selbstvorwürfe fühlten sich die Eltern gestärkt, die Rekonvaleszenz ihres Kindes zu unterstützen. Diese Zunahme an Selbstwirksamkeit CONTACT Adèle Lafrance
[email protected] Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada.
Department of Psychology, Laurentian University, 935
© 2017 World Association for Person-Centered & Experiential Psychotherapy & Counseling
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führte zu einer größeren Bereitschaft der Eltern, Verhalten an den Tag zu legen, das auf die Genesung fokussiert war. Diese Studie ist die erste, die eine Methode für Kliniker testet, wie man unterstützende Bemühungen verstärken kann, indem man die Selbst-Wirksamkeit der Bezugspersonen erhöht, indem man Emotionen prozessiert.
Aumento de la Auto-Eficacia Parental con la Terapia Familiar enfocada en la Emoción para Trastornos de la Alimentación: Un Modelo de Proceso Se ensayó un modelo de proceso en el que se buscó el miedo de los padres y la culpa de sí mismos para mejorar la autoeficacia de los padres y los esfuerzos de apoyo en el contexto de la terapia familiar enfocada en la emoción (EFFT, por sus siglas en inglés). Se administró una intervención de grupo de dos días de EFFT a padres de niños adolescentes y adultos con ED. Se recogieron datos de ocho centros de tratamiento (N = 124). Los datos se analizaron mediante pruebas t, análisis de regresión y modelización de ecuaciones estructurales. Los hallazgos apoyaron el modelo de proceso propuesto. A través del procesamiento del temor inadaptado de los padres y de su auto-culpa, los padres se sentían más capacitados para apoyar la recuperación de su hijo. Este aumento en la autoeficacia condujo a un aumento en las intenciones de los padres de participar en comportamientos centrados en la recuperación. Este estudio es el primero en probar un método para que los médicos aumenten los esfuerzos de apoyo dirigiendo y mejorando la autoeficacia del cuidador a través del procesamiento de la emoción.
Augmenter l’auto-efficacité parentale par la thérapie centrée sur l’émotion dans les cas de troubles de l’alimentation : un modèle de processus Dans le modèle de processus qui a été testé, la peur et l’autoculpabilité des parents ont été ciblées en vue d’améliorer l’autoefficacité parentale et les efforts de soutien dans le contexte de la thérapie familiale centrée sur les émotions (TFCE) dans des cas de troubles de l’alimentation. Une intervention de groupe TFCE d’une durée de deux jours a été dispensée à des parents d’adolescents et d’enfants adultes ayant un trouble de l’alimentation. Les données issues de huit sources (N=124) ont été collectées. Elles ont été analysées en utilisant le t-test, l’analyse de régression et le modèle d’équations structurales. Les résultats étayent le modèle de processus proposé. A travers la transformation des peurs et de l’auto-culpabilité inadéquates des parents, ceux-ci se sentent davantage en capacité de soutenir le rétablissement de leurs enfants. Cet accroissement de l’auto-efficacité engendre une augmentation des intentions des parents de développer des comportements centrés sur le rétablissement. Cette étude est la première qui teste une méthode destinée aux cliniciens pour intensifier les efforts de soutien en ciblant et en améliorant l’auto-efficacité des aidants via le traitement des émotions.
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Auto-eficácia Parental Crescente através da Terapia Familiar Focada na Emoção no tratamento de Doenças do Comportamento Alimentar: um modelo de processo Foi testado um modelo de processo dirigido ao medo e à culpa parental, de modo a incrementar a autoeficácia parental e os esforços de apoio às perturbações do comportamento alimentar (PCA), no contexto da Terapia Familiar Focada na Emoção (TFFE). Os pais de adolescentes e jovens adultos com PCA foram sujeitos a dois dias de intervenção em grupo de TFFE. Os dados de oito tratamentos foram recolhidos (N=124). Os mesmos dados foram analisados com recurso a testes-t, análises de regressão e modelos de equação estrutural. Os resultados apoiaram o modelo de processo proposto. Ao processarem o seu medo e o seu sentimento culpa disfuncionais, os pais sentiam-se mais aptos a apoiarem a recuperação dos seus filhos. Este incremento de autoeficácia conduziu a um aumento nas intenções dos pais em se envolverem em comportamentos focados na recuperação. Este é o primeiro estudo que testa um método no qual os clínicos aumentam os esforços de apoio ao se dirigirem e melhorarem à autoeficácia do prestador de cuidados, através do processamento das suas emoções.
Introduction Eating disorders (ED) are life-threatening illnesses that impact not only the affected individual but the family as well (Treasure et al., 2001). Recently, treatment models have emerged promoting the active involvement of parents in the treatment of ED across the lifespan (Family-based Therapy (FBT): Lock & Le Grange, 2012; New Maudsley Model (NMM): Treasure, Schmidt, & Macdonald, 2009; emotion-focused family therapy (EFFT): Lafrance Robinson, Dolhanty, & Greenberg, 2013). Positive outcomes for the affected individual and their caregiver have been reported across a number of family-oriented therapies (FBT: Lock et al., 2010; Le Grange, Crosby, Rathouz, & Leventhal, 2007; NMM: Goddard et al., 2011; EFFT: Lafrance Robinson, Dolhanty, Stillar, Henderson, & Mayman, 2014).
From emotion-focused therapy to emotion-focused family therapy EFFT emerged in part from the emotion-focused therapy (EFT) tradition. Initially, EFT proved very applicable and fruitful in the treatment of ED, particularly because of its approach to working with emotion (Dolhanty & Greenberg, 2007; 2009). Emotion is fundamental in the construction of the self and is a key determinant of self-organization (Greenberg, 2010). One of the goals of EFT is to support the development of mastery of emotional experience – that is to facilitate clients’ ability to perceive and emotionally respond to environmental situations in healthy and adaptive ways (Greenberg, 2008; Greenberg & Pascual-Leone, 2006). However, the notion of treating the individual and addressing their difficulties in processing and regulating emotions, in the absence of
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parallel work and change in the family to which they would return, has proven to have limitations for this treatment-resistant population. A number of clinical observations thus led to the consideration of a more explicit role for families in the treatment of EDs, moving them from a supportive role to a more integral role (Treasure et al., 2009), including in the emotional healing of their loved one using the principles of emotion processing and regulation (Lafrance Robinson, Strahan et al., 2013).
Emotion-focused family therapy EFFT is a transdiagnostic model of family therapy whereby caregivers are recruited to be actively involved in supporting their loved one’s recovery, regardless of the age of the sufferer, diagnosis, or duration of illness. Developed as an extension to individual and couple applications of EFT (Greenberg, 2010; Greenberg & Goldman, 2008), the primary aim of EFFT is to support and empower parents and carers to adopt a primary role in their loved one’s recovery. The therapy can be delivered in individual, family, and multicaregiver group therapy formats. Within each mode, there are three main domains of intervention which include supporting and educating carers in (1) recovery coaching by supporting their loved one with symptom interruption, (2) emotion coaching by supporting their loved one in the processing of emotions, and (3) engaging in a process of ‘relationship repair’ to facilitate the healing of old wounds and the release of child and caregiver self-blame. An overriding process throughout each of these three domains is the identification and processing of emotion experiences that block the parent from carrying out of the tasks of each domain or that lead to therapy-interfering behaviors such as denial, criticism, or accommodating and enabling behaviors. These behaviors are regarded as efforts to manage strong negative affect in the parent, in particular, fear and self-blame. For example, if they fear that their child will become suicidal if pushed too hard with refeeding, parents will avoid doing so in order to regulate their fear. This is regarded as a manifestation of a block and the underlying fear becomes the focus of the work. Once the block is processed and parents no longer fear the worst, they then feel empowered to take on the task and are able to regain access to their instincts and acquired skills. This means that rather than deeming parents as ‘unsupportive’ or their involvement as ‘inappropriate’, clinicians can target the emotions fuelling these processes and enlist parents as powerful and positive agents of change. Recently, a pilot study of a 2-day transdiagnostic group-based EFFT intervention was delivered to parents of adolescent and adult children with ED (Lafrance Robinson et al., 2014). Through education and experiential activities, parents were taught skills to refeed, interrupt symptoms, and support their child in processing and regulating emotion, including healing old wounds. Throughout the intervention, the focus shifted to supporting parents to process the emotional blocks that arose and interfered with their feelings of empowerment and supportive efforts in each of the domains. The intervention led to increases in a number of domains, including parental self-efficacy. This finding was particularly relevant given the recent research demonstrating that parental self-efficacy has been linked to both decreases in the child’s ED symptoms as well as to improvements in the mental health of both parent and child (Byrne, Accurso, Arnow, Lock & Le Grange, 2015; Lafrance Robinson, Strahan, Girz, Wilson, & Boachie, 2013). In fact, in a recent qualitative study exploring the core principles of treatment for
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Figure 1. Proposed mediation model.
adolescents with anorexia nervosa (AN), teams of clinicians identified parental selfefficacy as essential for recovery (Dimitropoulos, Freeman, Lock, & Le Grange, 2015). The authors also emphasized a need for a greater focus on addressing barriers to, and enhancing parental self-efficacy.
The current research The current study’s objective was to test a 3-step process model. In the context of an EFFT intervention, parental fears and self-blame were targeted in order to enhance parental selfefficacy and supportive efforts (Figure 1). Specifically, we predicted that a focus on processing parent blocks throughout the intervention will lead to reductions in parental fear and self-blame. Since it is known that parents lose access to their caregiving instincts when overwhelmed with emotion (Siegel, 2010), we also predicted that targeting and transforming these maladaptive emotion states would lead parents to regain access to feelings of selfefficacy vis-à-vis an active role in their child’s recovery. Finally, and in line with an emerging body of literature linking parental self-efficacy to carer and individual outcomes (Lafrance Robinson, Strahan et al., 2013; Byrne et al., 2015), we postulated that this increase in parental self-efficacy would positively predict ‘behavioral intentions’, that is parents’ intentions to adopt new recovery-based behaviors, in particular those targeted throughout the intervention. To our knowledge, this is the first research to investigate how an increase in selfefficacy will influence parents’ intentions to support their child in concrete and specific ways, namely by engaging in both recovery coaching and emotion coaching behaviors.
Method Description of intervention A manualized 2-day EFFT group intervention was delivered to parents of adolescent and adult children with ED. This transdiagnostic intervention was administered at eight sites across Canada in various treatment settings (hospital, community mental health, and
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private practice). The interventions were delivered by clinicians who received a minimum of 4 days of EFFT training as well as supervision specific to the manualized delivery of the group. Ethics approval was obtained for the study’s implementation at all sites. The primary objectives of the intervention were to teach parents practical skills to support their child’s behavioral and emotional recovery with an emphasis on processing emotional blocks that could interfere with the implementation of these skills. As such, the intervention included three domains of treatment, (1) recovery coaching via reefeding and interruption of symptoms; (2) emotion coaching and relationship repair; and (3) processing emotional blocks that emerged within the aforementioned domains. The group was designed to be skills based and interactive and as such included both didactic teaching and experiential activities (refer to Lafrance Robinson et al., 2014 for a more detailed description of the intervention).
Participants One hundred and twenty five parents, including 117 biological parents (81 mothers) and eight stepparents (three stepmothers) participated in the study. All parents completed questionnaires prior to participating in the intervention. The mean age of the affected individual was 18 years (SD = 5.12) and ranged from 12 to 41 years. Twenty percent of parents had a loved one on the wait-list for ED treatment, 60.8% of parents had a child involved in active treatment for an ED for an average of 1 year (range from 2 weeks to 8 years), while 19.2% of families were engaged in services not specific to an ED.1 In terms of symptom onset, 23.3% of parents reported their child first displayed ED symptoms less than 1 year ago, 37.5% between 1 and 2 years ago and 39.2% more than 2 years ago (ranged from 2 to 20 years). The mean duration of their loved one’s symptoms according to parental report was 3.16 years (SD = 3.62).
Measures Parental self-efficacy Parental empowerment was assessed using a revised version of the Parent versus Anorexia Scale (PvA; Rhodes, Baillie, Brown, & Madden, 2005). The PvA was designed to measure parental self-efficacy in the context of ED treatment, that is the ‘ability of a [carer] to adopt a primary role in taking charge of the [ED] in the home setting. . .’ (Rhodes et al., 2005, p. 401). Seven items make up the scale and these are rated on a 5point Likert scale from ‘strongly disagree’ to ‘strongly agree’. Scale total scores range from 7 to 35, with a lower scale score indicating a lower level of self-efficacy. This scale yields adequate psychometric properties (Rhodes et al., 2005). Carer Fear Scale Carer fear was measured with the Carer Fear Scale. This is a newly developed measure designed to assess the degree to which carers feel vulnerable to fears that can interfere with their ability to refeed their child and interrupt ED symptoms.2 Items were developed on the basis of clinical experience and carer feedback. Parents were asked to rate on a 7-point Likert scale (ranging from ‘not at all likely’ to ‘extremely likely’) the extent to which they feel vulnerable to four different fears when supporting their child’s behavioral recovery. Sample
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items include ‘Fear of breaking down or burning out throughout the process’ and ‘Fear of pushing my child too far with treatment and leading her to depression, running away, or suicide’. Scale total scores can range from 7 to 28 (α = .71). A higher score indicates a higher level of parental fear related to their engagement in recovery tasks.
Carer Self-blame Scale Self-blame was measured with the Carer Self-blame Scale, which was designed to assess the degree to which carers feel they are to blame for their child’s ED (Parents Traps Scale (PTS), Lafrance Robinson et al., 2014). Items were developed on the basis of clinical experience and carer feedback. Parents were asked to rate on a 7-point Likert scale (ranging from ‘not at all likely’ to ‘extremely likely’) the extent to which they felt responsible for their child’s ED. Sample items include ‘Fear of being blamed or to blame’ and ‘My worst fears will have come true – I will be to blame’. Scale total scores can range from 7 to 14 (α = .81). A higher scale score indicates a higher level of selfblame with respect to their child’s ED. Behavioral intentions Behavioral Intentions were examined to determine the extent to which parents’ anticipated engaging in the tasks of recovery coaching and emotion coaching following the intervention. To assess intention to change, parents were asked to complete this open-ended question: After this second day of the workshop, do you intend to do anything differently in the next day or two to support your loved one with meal support (refeeding/interruption of symptoms), emotion coaching or relationship repair?
Parents’ intentions to change were analyzed using consensual qualitative research analysis of the responses (Hill et al., 2005; Yeh & Inman, 2007). These were coded in three steps: (1) major themes related to the intervention were identified as initial coding categories: recovery coaching and emotion coaching. Intentions related to refeeding, meal support, or the interruption of symptoms were coded under the recovery coaching domain. Intentions related to emotion coaching (either the steps of emotion coaching or relationship repair) were coded under the emotion coaching domain; (2) to increase reliability, two separate coders independently categorized each of the participants’ answers using the coding scheme and determined the total number of strategies that were mentioned for each domain; (3) the two coders then reviewed each assigned rating to arrive at a consensus. Inter-rater reliability for both domains was strong (recovery coaching domain α = .93; emotion coaching domain α = .93).
Results Parental self-efficacy We predicted that parents would increase in self-efficacy over the course of the intervention. To test this, we conducted a paired samples t-test comparing parental self-efficacy at Time 0 and Time 1. This test revealed a significant effect for time, t (118) = −16.30, p = .0001. Parents showed a large increase in self-efficacy over the course of the intervention
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Table 1. Multiple regression results for parental fear and blame on self-efficacy. Parental fear Parental blame
b
t
p
R2
−.296 −.323
−3.36 −3.67
.001
